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Columbia City SERVE Parent/Guardian Release Form
Find us on the web
www.thecenterwcy.com
For Questions, Contact: Jonathan Johnson - SERVE Director
jj@thecentercc.com
or (260) 248-4977
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* Indicates required question
Household/Family Information
Primary Adult Contact First Name
*
Your answer
Primary Adult Contact Last Name
*
Your answer
Relationship to Student
*
Mother
Father
Grandparent
Other:
Please select all that apply
Is Emergency Contact
Lives in the same household as the student
Primary Contact Street Address
*
Your answer
City
*
Columbia City
South Whitley
Churubusco
Other:
State
*
Indiana
Other:
Zip Code
*
46725
46787
46723
Other:
Primary Adult Phone Number
*
Your answer
Primary Adult Email Address
*
Your answer
Household Type (Who lives at home with the student?)
*
Both Parents (Married)
Both Parents (Unmarried)
Mother Only
Father Only
Both Grandparents
Single Grandparent
Other:
Required
Family Size (# of Kids & Adults living at home)
*
2
3
4
5
6
7
8 or more
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